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Date of Birth MM/DD/YYYY*

Street Address

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Insurance (HMO, PPO, or MEDICAID)

Appointment Date Requested

Appointment Time Requested

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Are you a new patient? Are you a new patient? Yes No

Gender Gender Male Female unspecified

QR Code for Additional Fee QR Code for Additional Fee Yes No Not testing for COVID

Reason for COVID Test Reason for COVID TestNot Testing For COVID-19Experiencing symptomsExposureCity MandateTravel (Cruise/ International)Attending EventWork (Return to work requirement/ Employer mandate)School (Return to school mandate)

What COVID test do you need? What COVID test do you need? RAPID Antigen RT-PCR Not Sure

Reason for Your Visit

Name, date of birth, and passport # from everyone in the group.